Wylie, Connie Marie , 'V LF 1 St 1 Z 10
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Connie Marie Wylie Female
Date of Death Age If Veteran of U.S.Armed Forces,
11/25/2022 65 Years War or Dates
1— Place of Death Hospital,Institution or
Z City,Town or Village Granville Town Street Address 10280 State Route 22,Granville Town, New York 12832
11.1
O Manner of Death a Natural Cause nAccident ❑Homicide Suicide Undetermined ❑Pending
IJJ
O Circumstances Investigation
W Medical Certifier Name Title
O W Day PA
Address
79 North Street,Granville Town,New York 12832
Death Certificate Filed Town Of Granville District Number Register Number
City,Town or Village 5756 65
EBurial Date Cemetery,Crematory or Facility Name
11/28/2022 Pine View Crematory
Entombment Address
Cremation Queensbury Town,New York
Donation
o❑Removal Date Place Removed
and/or and/or Held
H Hold Address
N
0
d Date Point of
N Transportation
0 by Common Shipment
Carrier Destination
Disinterment
Date Cemetery Address
EI
Reinterment
Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Regan Denny Stafford Funeral Home 01443
Address
53 Quaker Rd,Queensbury,New York 12804
Name of Funeral Firm Making Disposition or to Whom
,— Remains are Shipped,If Other than Above
a Address
CC
W
C' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 11/28/2022 Registrar of Vital Statistics .franyLinrfaaf!fartelle(fYectronicaf Signed
(signature)
District Number 5756 Place Town Of Granville
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
I—
Z Date of Disposition It I 2L Place of Disposition _
111
(abdress/
1- 6
N Cr (section) /f (lot number) (grave number)O Name of Sexton or Person in Ch e of Premises t'r
Z (p se print)
Ill Signature / /Iil Title Ci
DOH-1555(07/18)p 1 of 2
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# __